Avoid Carnitine and Lethicin Supplements

Avoid Carnitine and Lethicin Supplements
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A landmark study in the New England Journal of Medicine shows that choline in eggs, poultry, dairy and fish produces the same toxic TMAO as carnitine in red meat, which may help explain plant-based protection from heart disease.

Earlier this year, a research team at the Cleveland Clinic offered another explanation as to why meat intake may be related to mortality (see, for example, Harvard’s Meat and Mortality Studies). They noted that “Numerous studies have suggested a decrease in atherosclerotic disease risk  [our  number 1 killer] in vegan and vegetarian individuals compared to omnivores,” but reduced intake of dietary cholesterol and saturated fat may not be the full story.  The researchers found that within 24 hours of carnitine consumption—eating a sirloin steak, taking a carnitine supplement—certain gut bacteria metabolize the carnitine to a toxic substance called trimethylamine, which then gets oxidized in our liver to TMAO, trimethylamine-n-oxide, which then circulates throughout our bloodstream. There’s a diagram in my 9-min video Carnitine, Choline, Cancer and Cholesterol: The TMAO Connection.

The way we know it’s the gut bacteria is that if you give people antibiotics to wipe out their friendly flora, you can apparently eat all the steak you want without making any TMAO, but then if you wait a couple weeks until your gut bacteria grows back, you’re back to the same problem.

What’s so bad about this TMAO stuff? It appears to increase the buildup of cholesterol in the inflammatory cells in the atherosclerotic plaques in our arteries, increasing our risk of heart attack, stroke, and death. The role of these inflammatory “foam” cells (so-called because they’re so packed with cholesterol they look foamy under a microscope) is explained in my video series that starts with Arterial Acne and Blocking the First Step of Heart Disease.

What does carnitine do? It’s involved in energy production in the mitochondria (“power plants”) in our cells. The enzyme that uses carnitine to help us burn fat, carnitine palmitoyl transferase, is actually upregulated by about 60 percent in those eating meat-free diets, which may help explain why those eating plant-based diets tend to be slimmer. More details in my video How to Upregulate Metabolism.

How do we keep carnitine away from our gut bacteria? Well there’s zero dietary requirement; our body normally makes all that we need. The problem is that the bodies of other animals also make all that they need so when we eat them, their carnitine can end up in our gut for those bacteria to feast upon, resulting in TMAO.

Some animals make more carnitine than others. Carnitine is concentrated in red meat, and so this new body of research has led to recommendations to decrease red meat consumption as well as avoid carnitine-containing supplements and energy drinks.

What most media reports missed, though, is that gut bacteria can turn the choline found in eggs, poultry, fish, dairy, and lecithin supplements into TMAO too. So it’s not just a problem with red meat. The good news is that this may mean a new approach to prevent or treat heart disease: “The most obvious is to limit dietary choline intake.” But if that just means decreasing egg, meat and dairy consumption, the “new” approach sounds just like the old approach.

Unlike carnitine, we do need to take in some choline, so should vegans be worried about the modest amounts of choline they’re getting from beans, veggies, grains, and fruit? And same question with carnitine. There’s a small amount of carnitine found in fruits, veggies, and grains as well. Of course it’s not the carnitine itself we’re worried about, but the toxic TMAO, and you can feed a vegan a steak without getting a TMAO spike. Literally. The researchers convinced a long-time vegan to eat an 8-ounce sirloin, in the name of science. The vegan got the whopping carnitine load, but hardly any TMAO was produced. Apparently, the vegans don’t develop those TMAO-producing bacteria in their gut, and why would they?

It’s like the whole prebiotic story I detail in videos like Boosting Good Bacteria in the Colon Without Probiotics. When we eat a lot of fiber, we select for fiber-munching bacteria, and some of the compounds they make with fiber are beneficial, like the propionate that appears to have an anti-obesity effect I explored in Fawning Over Flora. It seems that if we eat a lot of animal products we may instead be selecting for animal-munching bacteria, and some of those waste products—like the trimethylamine—may be harmful.

-Michael Greger, M.D.

PS: If you haven’t yet, you can subscribe to my videos for free by clicking here and watch my full 2012 – 2014 presentations Uprooting the Leading Causes of Death, More than an Apple a Day, and From Table to Able.

Image credit: avlxyz / Flickr

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  • Mindy

    Is it safe for vegans to take lecithin granuiles?

    • Dan

      Mindy, I would most definitely avoid this. Since lecithin is essentially phosphatidylcholine, you are giving yourself a very high dose of the choline found mainly in eggs and red meat (and in much lower quantities in other plant foods). This is what happens when you take a whole food like soybeans and concentrate certain small portions of it like soy lecithin.

  • Richard Herbin

    Would the same issues be associated with Acetyl-L-Carnitine, which is combined with alpha lipoic acid in supplements that are claimed to improve mitochondrial health? Thanks Dr. G.

    • Dikaiosyne

      The following may be helpful: “Carnitine Study: A Response, April 2013″ at http://lpi.oregonstate.edu/news/CarnitineStudyResponse.html

      From the article:

      “Right now, we have a large body of work that has accumulated over decades that acetyl-l-carnitine and lipoic acid are safe to use at appropriate doses. Acetyl-l-carnitine alone has been given clinically at very high doses (as much as 8 grams per day) with no observed side effects, including those suggested by this study.”

      • Richard Herbin

        Thanks, very relevant and helpful.

  • stacy

    I’ve had tests done that show I’m very low in choline and carnitine… What does someone in my situation do?

  • A. Bruton

    Your article –Avoid Carnitine and Lethicin Supplements
    I don’t see anything in this article regarding Lethicin

    Question–
    Is Phosphatidylserine,— enriched sunflower Lecithin.

    the same thing?
    I take this supplement for memory enhancement.
    I have checked your web site and there is nothing shown about Lecithin.

    • Courtney

      I would imagine that it may depend on where the lecithin is sourced. It is my understanding that it can be either Soy or Egg derived. This article refers to choline found in eggs.

      Perhaps structurally or chemically the body may metabolise choline derived soy differently? I would love to hear other opinions on this, as I frequently recommend Lecithin granules (soy derived) to my patients. Interesting article, thank you for posting.

      • A. Bruton

        Do you know if Lecithin and Lethicin are the same thing?
        The Lecithin I use is from Sunflower Oil

        • Laurie Masters

          Lethicin is somebody’s misspelling.

  • RockVeg

    I’m vegan and have suffered with anxiety/panic disorder since my childhood and was told by my psychiatrist to take choline and inositol. It’s been a huge help!

  • Mindy

    I thought that the bad lecithin was from GMO soy and in all of the over processed foods like ice cream, desserts, frosting etc. My understanding is that non gmo lecithin is ok and that our brains have a minimum of 30% lecithin. Don’t we need it as we age and lose fat around our nerves? Dr. G, can you please weigh in?

    • Toxins

      The only dietary fat we need is omega 3 and omega 6. All other fats are synthesized by our body.

  • Kim

    I am Vegan but have gall bladder attacks (low ejection fraction) and have been prescribed Lecithin in large quantities. How problematic is this?

    • http://www.DonForresterMD.com/ Don Forrester MD

      Lecithin is generally regarded as safe but it does contain alot of fat. Fat stimulates gallbladder contraction and may contribute to attacks. It has been shown in combination with other substances to help reduce the size of gallstones. Of more concern as Dr. Greger points out is the possible connection with increased heart and arterial disease. For most of my patients with gall stones I recommend low fat plant based whole food diets. If you can avoid attacks it doesn’t matter if you have gall stones. Unfortunately once you have them they sometimes need to be removed. Work with your physicians and keep tuned in to NutritionFacts… you never know what scientific studies will reveal next.

  • peterz

    A little confused…. if elevated TMAO, which is harmful, is a function of carnitine intake in combination specific gut microbes, which are in turn a function of routinely eating animal protein, then -
    Is there an issue with taking supplements of carnitine (or choline) if one is a 100% plant based and thereby has a different makeup of gut microbes ?

  • Alex Pollack

    Is your advice about carnitine the same for L-Carnitine?

    • http://www.DonForresterMD.com/ Don Forrester MD

      I would avoid both. Throwing into the human body concentrated singe nutrients is in my opinion not a good idea.

      • Tired boomer!

        Melatonin?

  • Dan

    I would avoid lecithin supplements, L-carnitine, choline, phosphatidylcholine, etc, even for vegans and vegetarians. The reason is excessive TMAO elevations, even in vegans. Dr Hazen has demonstrated a great “proof of principle”:

    When you take a whole foodstuff like soybeans and extract one of tens of thousands of molecules in that food (such as soy lecithin), purify that one molecule to extremely high quantities, and then ingest that one molecule in those extreme quantities every day into the body, you are messing with nature’s way and our body’s way of protecting us against excessive toxicity from individual molecules consumed in great amounts.

    This is why micronutrient supplement trials are nearly always negative for hard endpoints like death, stroke, heart attack, etc. But when you take in the whole food, you get the cofactors and coenzymes that mitigate or modulate absorption – nutrition is overwhelmingly complex with many interactions at the molecular and cellular level.

    As another example, given by T Colin Campbell in his book “Whole”, eating a vitamin C tablet is entirely different than eating an apple, because with the latter you get rafts upon rafts of antioxidants and phytochemicals, whereas with the former you get immense quantities of a single antioxidant, the quantity of which may be entirely inappropriate to your internal milieu. Same thing goes with beta carotene and retinoic acid.

    • http://www.DonForresterMD.com/ Don Forrester MD

      Nice post… add Vitamin A and E to the list. Caution should also be used for “vitamin” D which is also fat soluble and is easily stored.

      • Dan

        Also one could add inorganic calcium supplements, folic acid, magnesium, beta carotene, retinol, tocopherol … all have shown harms in large randomized trials.

        • Timar

          I don’t think that magnesium has ever shown any harm (other than diarrhea) in randomized trials. There are some concerns about folic acid, but the most recent and comprehensive meta-analysis haven’t shown any increased risk of cancer from high dose folic acid.

          Of course, if you eat a plant-based diet including nuts and legumes, you’ll probably get plenty of magnesium and folate from food and don’t need supplements.

      • b00mer

        Aside from B12, vitamin D is the only one I think I should supplement. I go on and off it, taking it for a few weeks (in line with Dr. G’s recommended amounts), then not, kind of wary of it due to the risks seen with the other fat-soluble vit supplements. Getting enough sunlight is not an option where I live, any time of year, and frankly I try to minimize exposure anyway with my cornucopia of skin cancer risk factors. So I’m wondering, at the end of the day do you still recommend supplements if sunshine is not an option? Do you advise the higher amounts Dr. Greger has recommended compared to the standard rda? Jeff Novick wrote on the connection between obesity and vitamin D deficiencies which has me wondering about the higher recommendations.

        • http://www.DonForresterMD.com/ Don Forrester MD

          I think supplemental Vitamin D is a good option for folks who don’t have access to sunlight. There are other considerations like a history of skin cancer. So the recommendations have to be individualized. As far as levels go I err on the conservative side. I have been practicing for over 35 years and have seen fads, drugs, over-treatment recommendations come and go. Given my additional training in statistics and knowledge about complex systems I believe it would be nice to have some baseline information to help establish what is normal for each individual. Given the typical bell shaped curve in most populations there is variability in what is normal from person to person. One study Dr. Greger reviewed mentioned lifeguards in Hawaii with Vitamin D levels in the mid 20′s. I certainly wouldn’t recommend Vitamin D for that population. So I don’t think there are right or wrong answers but working with your regular doctors and keeping up with the science will help you make the best decision. Good luck.

    • Humzee

      The example of vitamin C being better consumed with foods may not apply here. Most animals have the ability to make their own vitamin C, ascorbic acid, in their liver or kidneys. Humans of course, have given up this ability many thousands of years ago. When a 150 pound goat makes 13 grams of ascorbic acid a day (on an average day), it makes 13,000 mg of ascorbic acid. No rutin. No hesperidin. No bioflavanioids. When getting ascorbic acid from foods (instead of from our liver), the associated factors are helpful in their own right, but not necessary to the overall function of the ascorbic acid. Indeed getting vitamin C intravenously may be the most “natural” way to get vitamin C in the sense that that is the way our body is programmed to receive it – in the blood stream directly. This intravenous vitamin C use has proven to be the most effective anti-viral, anti-bacterial, anti-fungal treatment known to man (but apparently “unknown” to profit-making, pharmaceutically driven “modern” medicine)…

  • ReachforNutrition

    This is a very helpful article – thanks Michael -especially interesting for avoiding heart disease! http://reachfornutrition.co.uk

  • Gadea

    What about UDO oil?
    What is your recommendation on UDO Oil?

  • Wegan

    What is the name of the TMAO producing bacteria?

    • http://www.vegannd.com/ Dr. Connie Sanchez, ND

      The species Acinetobacter have been identified as TMAO producing bacteria.

      • http://www.DonForresterMD.com/ Don Forrester MD

        Given the number of different bacterial species in the colon (e.g. one article mentioned almost 300) I would posit that there will be more found. Of course talking about single bacteria in the setting of complex or adaptive ecosystems reflects a reductionistic approach… not good or bad… just something to keep in mind.

  • https://www.louisdallaraphotoblog.com/ Louis Dallara

    Correlation does equal causation!

    • http://www.vegannd.com/ Dr. Connie Sanchez, ND

      True, however, until the science is worked out, it is better to err on the side of caution.

      • Timar

        Oops, wrong place

  • Paul Spring

    Dr. Geger’s message leaves me confused. It is my understanding that l-carnitine can be deficient in vegans, as is B12. If this is so, and if the culprit is bacteria creating TMOA, why put the blame on l-carnitine? Intravenous l-carnitine clearly does not experience the gut environment. Maybe a more sparse used of l-carnitine would allow increased build up in a vegan’s bloodstream and tissue but be infrequent enough to not allow the culprit bacteria to take hold.

  • Carl Newmeyer

    “They noted that “Numerous studies have suggested a decrease in
    atherosclerotic disease risk [our number 1 killer] in vegan and
    vegetarian individuals compared to omnivores”

    This doesn’t factor in how much veggies a meat eater consumes. I find the meat eater vs vegetarian argument vague. I would say perhaps most meat eaters just don’t eat enough veggies.

    To me the question is how much veggies do your meat eaters eat? –and what else do they eat? So can this be studied somehow? Maybe this would answer what is really going on health-wise.

    • Timar

      I think the evidence points towards a *mostly* plant based diet, comprising small amounts of healthy animal products (i.e. fish and cheese) as being the best diet for optimum health. This is what corresponds best to our evolutionary defined nutritional needs and what epidemiological studies have shown to be most strongly associated with longevity.

      See this very thoroughly done German study on the mortality risk of long-term vegetarians and health-conscious non-vergeterians: http://cebp.aacrjournals.org/content/14/4/963.long Those poeple who fared best where not strict vegetarians but those who ate small quantities of animal products.

      That may be, as Dr. Greger suggests, because of the vitamin D, B12 and long chain omega-3 fatty acids in animal food, so you theoretically could obtain the same benefits by eating a strictly vegeterian diet supplemented with those nutrient. However, I have to object that it may as well be because of other lesser known nutritional factors in animal products.

      It is like Michael Pollan put it: “Eat food, not too much, mostly plants”. It’s the “mostly” that is key here – you don’t need to make an “exclusively” out of it.

      • Paul Spring

        Timar – May or may not be true that “small amounts of “fish and cheese” may be optimal – in an ideal world. But the dangers of toxins present in fish are real and there is no valid data on prehistoric humans or any compelling reasons to classify animal-derived food as anything more than an option for survival. Since we now understand the importance of B-12, the need to get it derived from gut-based bacteria in animals is no longer relevant. Given that folks who live solely on plant-based diets do so much better than omnivores, other than habit and cravings, why bother to eat animal products?

  • Stephen Severance

    I am a Hepatologist (Liver Specialist), but the fact that 65% of all liver disease in the USA is due to “fatty liver” related to our diet has transformed my practice and most of my study into an obesity and nutrition clinic. I refer all my patients to this link and have the utmost respect for Dr. Gregor, but in this case have to disagree. Almost simultaneous with the NEJM report he cites, the Mayo Clinic Proceedings published a meta-analysis (summary of several studies) showing the taking an L-carnitine supplement reduced death rate by 27% in patients who ALREADY HAD HEART DISEASE.(http://www.mayoclinicproceedings.org/article/S0025-6196%2813%2900127-4/fulltext ). 3 months later an excellent review in the same journal ((http://www.mayoclinicproceedings.org/article/S0025-6196%2813%2900462-X/fulltext) very convincingly refuted the conclusions of the NEJM article cited by Dr. Gregor. Among many impelling facts cited in that refutation, is that fish, which no one disagrees is beneficial for the heart, contains over 5 times the TMAO (the putative heart toxin produced from choline and carnitine) as red meat generates. For the record, and relevant to some of the questions below, I am a 71 year old fit healthy vegan who has taken L carnitine and lipoic acid and small doses of choline for years.. My last cholesterol was 150, 60 of which was HDL (“good”), my blood pressure is 110, and I take no medications other than supplements.

    • Timar

      Thank you for the links. The meta analysis and the enlightening comment by Mark McCarty provide definitive evidence against the TMAO hypothesis. I think this is an instructive example of how researchers more or less knowingly practise selective perception and ignore facts which contradict their hypothesis. In this case I think Koeth at al. knowingly chose to ignore everything they should know about fish consumption in order to publish a headline-grabbing paper in a prestige journal. Of course Dr. Gregor and other advocates of a strictly plant-based diet would claim that fish is an unhealthy food too, but to be perfectly honest, as much as I respect Dr. Gregors work, don’t expect any objectivity from him when is comes to animal foods. There is an overt ideological bias here against those foods which doesn’t allow for any objectivity (however, such kind kind of bias seems much more honorable to me than th calculated bias shown by researchers like Koeth). I think nutritionfacts.org is a great source to learn more about the health benefits of plant foods and just ignore the obvious vegan propaganda.

      • Thule

        Well see the conclusion of the article cited above by Stephen Severance

        Health experts generally acknowledge that the negative health impacts of
        diets rich in red meats are largely attributable to high intakes of
        saturated fat, heme iron, bioavailable phosphate, and carcinogens
        induced by cooking or interaction with nitrite preservatives.
        Ironically, in seeking to incriminate red meat’s carnitine content,
        Koeth et al may have pointed the finger at one of red meat’s few saving
        graces.

        So even if the jury is still out regarding carnitine as
        an isolated *suplement* that doesn’t save the day for meat and fish
        (fish is loaded with problems as well, besides the contamination levels)
        Get informed.

        Regarding the German study, let’s remember that we
        are facing here of a new paradigm, people who go vegan are still
        learning how to manage their diet, most don’t supplement with B12, even
        more have no clue about omega 3 intakes.

        Now we know many of the
        factors that make the typical diet so prejudicial — while the experts
        are trying to learn about the huge amount of nutrients still unknown to
        science, the hundred of thousands of phytochemicals in plants, and how
        our health depends on them.

        People in “flexitarians” diets
        aren’t relatively healthy because of adding know problematic or
        downright dangerous foods, but despite of it.

  • Markus

    So you would also have to avoid choline due to TMAO, right?

    Among the food with the highest intake is not only meat and egg yolk but also wheat germ, broccoli, sunflower lecithin or amaranth:

    http://en.wikipedia.org/wiki/Choline#Food_sources_of_choline

    perhaps one should do the TMAo test with those foods, too. Preferrably with n>1 this time ;o)

    • Timar

      As I have written in another post, which, curiously enough, didn’t made it through the moderation, trimethylglycine aka betaine is a compound closely related to choline and carnitine and is metabolized to TMAO by gut bacteria in the same way. So if you really believe Koeth’s hypothesis, spinach and quinoa are much worse offenders than red meat, as both contain about 600mg/100g – which is about six times as much as the carnitine content of red meat.

      If you think about it, it is incredible how such a shaky concoction of inadequate studies, glued together by a half-baked, counterfactual hypothesis, made in into a journal like Nature Medicine. It really throws a bad light on the standards of medical publishing. It seems you just have to work in a prestigious instituttion, come up with a headline-grabbing hypothesis, lump together a paper in the way described above (while persistently ignoring the vast amount of research that contradicts your thesis) and voila – you have your high-impact publication and make headlines in the mass media.

      It’s a sad joke, really.

      • Markus

        Hi Tmar,

        could it perhaps be that the study’s author or the lector are vegans?

        Myself I’m taking 2gr Carninite (ALCAR) as supplement daily, I do have trust into Dr Bruce Ames who is still dancing the Macarena with his 85 years :o)

        • Timar

          I don’t think so. They just follow the prevailing paradigm that red meat causes artherosclerosis, which, by the way has been called into question by the largest and most recent epidemiological study on meat consumption and mortality risk, which found *no* association: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3599112/

          I wrote a lengthy reply to Thule’s post above, mentioning that study but, alas, it went into moderation. I’d by surprised if they publish it. Quite frustrating if you take time to write a factual, polite and comprehensive reply and then it gets cens0red…

          • Thea

            TImar: As far as I know, none of us at NuritionFacts censor anything but the most offensive of posts (those with bad language, etc.). What I have personally noticed is that Discus, the software/company which runs the comment section, does not always display all of the comments. I don’t know why, and it drives me nuts. But if I keep the original post in my e-mail, I’m often able to find posts again on the NutritionFacts page. You have to force Discus to display what you want.

            Just wanted to let you know that respectful, differing opinions are very welcome at NutritionFacts as far I have seen. (Posts don’t even have to make sense or be accurate. I’m not saying anything about your posts. I’m just saying that if we actually monitored this site for content, we would have deleted a great many comments.)

            Hope that helps.

  • Paul Spring

    I guess I’m missing something. I thought the thrust of the journal article in question was to show the link between gut bacteria, carnitine and TMAO. I think that’s a pretty amazing discovery. The “conclusions” and conjectures regarding the risks of red meat may or may not be valid in this case – but the science seems to be pretty solid.

  • Declan Gerard King

    As a reminder , we are noy going to get out of this alive . Enjoy the moment , abraco!

  • Annie

    This is interesting. A vegan has defenses against a spike in TMAO. I wonder what would happen if someone who eats a variety of meats, but also consumes abundant antiinflammatory veggies ( like spinach, kale ) were given the same test. In other words, a healthy and varied diet. Perhaps this points to everything in moderation and to eat a variety of high quality, nutritious foods, and avoid highly inflammatory foods like white flour, wheat and sugar.

  • ruthness

    so then, if you require extra carnitine as a vegan it is safe to supplement acetyl-l-catnitine? But not if you are a meat eater?